“We’re telling those people that we’re not going to pull the rug out from under them, and if we do this too fast, we are in fact going to pull the rug out from under them.”

– Rep. Tom MacArthur (R-N.J)

“The fact is, we cannot repeal Obamacare through reconciliation.We need to understand exactly: what does that reconciliation market look like.And I haven’t heard the answer yet.”

– Rep. Tom McClintock (R-Calif)

“It sounds like we are going to be raising taxes on the middle class in order to pay for these new tax credits.”

– Sen. Bill Cassidy (R-La)

These quotes, and many others, from a leaked recording of the Republican closed-door strategy session in Philadelphia last week are both jarring and reassuring.

They reveal in harsh light what the media, pundits, and commentators have been saying for weeks: the Trump administration and congressional Republicans are in a deep quandary about the best path forward on repeal and replace, and are just beginning to weigh the pros and cons of the complex policy options involved.

But the discussion also shows us that rank and file Republican lawmakers understand the difficulty of the task and know the political price they’ll pay if they screw it up. Their remarks also imply frustration with the cavalier, ill-informed, and mixed-message statements coming out of the White House.

Trump himself addressed the group.Paraphrasing:Obamacare is a disaster.It’s a disaster.We could just let it die on it’s own because it’s a disaster and the Democrats will come begging us to fix it.But we have to do something to help the people…by fixing the disaster.

Dr. Tom Price (R-Ga)—Trump’s nominee to be HHS Secretary—did his best to stay above the fray at his confirmation hearing on Tuesday Jan. 24.He shed almost no light on what repeal and replace should look like or on what timeframe it should be done.He was poised and steady, and even charming at times, but also sly and deeply less than forthright.Of course, he was quite busy fending off charges that he sought legislation numerous times that benefited companies he had invested in.

His evasive answers were almost comical at times.In case you missed it:

Sen. Sherrod Brown (D-Ohio):“President Trump said he’s working with you on a replacement plan for the ACA, which is nearly finished and will be revealed after your confirmation.Is that true?

Price:“It’s true that he said that, yes.”(The packed room breaks into laughter, according to The Washington Post.)

Brown:“Did the president lie about this, that he’s not working with you?”

Price:“I’ve had conversations with the president about healthcare.”

Make no mistake, the loose and evasive talk and the actions Trump has taken so far (the one-page executive order and the enrollment outreach directive), are already having an impact. Consumers, including my 29-year old daughter, are wondering if they’ll be able to keep or have access to ACA exchange insurance, and if it won’t be crappier coverage for the same or more money.Insurers are reevaluating exchange participation for 2018.Employers see only disruption ahead, and worry about over-reliance on shifting costs to workers with a failure to address underlying costs.Governors, Democrat and Republican, are worried their Medicaid expansions are in jeopardy.

By the way, the administration did not brief Republican leaders in Congress, or governors, on the executive order until one day before it was issued.

And in an inexcusable misstep, the White House last Thursday issued a directive to halt all exchange enrollment outreach and advertising before the Jan 31 enrollment deadline.Less than 24 hours later, after a tsunami of criticism, the White House pulled back on some of the order but kept a limit on ads.Said a spokesperson:“We aren’t going to continue spending millions of taxpayer dollars promoting a failed government program.”

I could get just as partisan here.After all, the Republicans have been the gang that couldn’t shoot straight on healthcare for 50 years.They have never supported universal coverage or a right to health care, and have fought most coverage expansions.They didn’t support the creation of Medicare and Medicaid in the early 1960s until Lyndon Johnson twisted arms.They fought Medicaid expansions for the next 40 years—a program that now provided a lifeline to 70 million low- and middle-income Americans.They viciously killed Hillarycare and stonewalled passage of the ACA.The sole exception is George W. Bush’s successful push for a prescription drug benefit for Medicare beneficiaries.

And, of course, they have spent the last six years spreading falsehoods—I guess we can call those lies or propaganda now—about Obamacare.“Government-run healthcare.” “Costs taxpayers billions.”“Death panels.”“Comes between you and your doctor.”“Much more expensive coverage.”

(In fairness, Obama himself and other ACA proponents have uttered their share of falsehoods and used propaganda to sell and advance the ACA.)

The hope at this point—and it’s a long shot, I know—is that both sides lower the temperature of the rhetoric, agree on the complexity of the task ahead, and start getting down to brass tacks to design a replacement (because, the ACA is going to be repealed) which preserves what works in the ACA.Call it whatever you want.In the meantime, no repeal and delay. It’s quite clear that is a dangerous path that will end up harming mullions of Americans.

The policy preferences of both sides can be knit together.It won’t be easy but it can be done. As one example, both sides can almost certainly rally around more state flexibility, possibly in the short term.There’s a partial ACA repeal bill already in the hopper on that as of last week, with Cassidy of Louisiana and Susan Collins of Maine as sponsors.

As for the politics, the Republicans need 60 votes in the Senate to pass a meaningful replacement that avoids doing serious damage to the individual insurance market.It would be better to get to 65 or 70.That way, the replacement is truly bipartisan and modifications needed it the future can be debated in that spirit.

It’s way past time to stop the nonsense and hyper-partisanship on healthcare. Lives hang in the balance.

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